Pitfalls

Non-resolution of acidosis and ketosis

*Table 3: Causes of persistent acidosis and ketosis in young people with DKA*
Acidosis not improving	Ketosis not improving
Insufficient insulin or drug error?	Check infusion lines
Inadequate resuscitation?	Insufficient insulin prescribed?
Underlying sepsis?	Incorrect preparation of insulin infusion?
Hyperchloraemic acidosis? (related to excessive use of chloride containing fluids)	Inadequate fluid input?
Recreational or prescription drugs?	Underlying sepsis?

Cerebral oedema

Fig 16: Cerebral oedema is a potentially life-threatening complication of DKA in young people

Cerebral oedema has high mortality and morbidity[11-12,58]

Late signs are associated with extremely poor prognosis.

Senior staff must be informed immediately if suspected.

Discuss with PICU consultant & arrange urgent transfer.

Immediate management of cerebral oedema involves the following[22]:

Exclude hypoglycaemia
Give hypertonic (2.7%) saline or mannitol urgently
Adjust IV fluids
Reduce to 1/2 maintenance
Do not intubate and ventilate until an experienced doctor is available
Once stable a CT scan should be conducted to exclude other intra-cerebral events (thrombosis, haemorrhage or infarction) that have a similar presentation

*Table 4*
Warning signs[22,25]	Risk factors[25]
Headache	Younger age[63]
Change in neurological status (reduction in GCS, change in restlessness, irritability or incontinence)	Initial presentation of T1DM[9,63]
Focal neurological signs (i.e. cranial nerve palsies)	Longer duration of symptoms[64]
Relative bradycardia & hypertension (Cushings reflex)	Greater volumes of fluid within the first 4 hours of treatment[33,65-66]
Reduced oxygen saturations	Insulin infusion started within the first hour of treatment[33]
Abnormal posturing	Use of bicarbonate during treatment[11,67]
Oculomotor palsies, pupillary inequality or dilatation	Greater hypocapnia at presentation[11,65,68]
Late signs: convulsions, coma, papilloedema, respiratory arrest	Increased serum nitrogen at presentation[11,68]
	More severe acidosis at presentation[33,66,69]

Accurate documentation

Fig 17: Accurate documentation is required in the management of all critically ill patientsAs with all critically ill patients ensure notes are:

As with all critically ill patients ensure notes are:

Timed (24 hour clock) & dated
Legible, accurate, sufficiently detailed & contemporaneous as possible
Completed with the clinician’s name, designation & signature
Complete with regards to discussions with senior colleagues & that the advice given is clearly documented